A nurse is caring for a client diagnosed with stage 4 cancer who has a prescription for a subcutaneous morphine sulfate patch for pain.
The client is short of breath and difficult to arouse.
During a head-to-toe assessment, the nurse finds four patches on the client’s body. What should be the nurse’s first action?

Administer a narcotic reversal drug.

Apply an oxygen face mask.

Remove the morphine patches.

Monitor the client’s blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering a narcotic reversal drug is not the first action the nurse should take. While it’s true that the client’s symptoms could be due to opioid overdose, the nurse should first confirm the cause of the symptoms. In this case, the nurse finds four patches on the client’s body, which is unusual and could lead to an overdose. Therefore, the first action should be to remove the patches to prevent further absorption of the drug.

Choice B rationale

Applying an oxygen face mask might be necessary if the client is having difficulty breathing. However, this would not address the underlying problem if the client is experiencing an overdose from the morphine sulfate patches. The nurse should first remove the patches to stop further drug absorption.

Choice C rationale

The nurse finds four patches on the client’s body. This is unusual and could lead to an overdose. Therefore, the nurse’s first action should be to remove the patches to prevent further absorption of the drug. After removing the patches, the nurse can assess the client’s condition and provide further interventions as needed.

Choice D rationale

Monitoring the client’s blood pressure is an important nursing intervention, but it should not be the first action in this situation. The nurse has already found a potential cause for the client’s symptoms (i.e., the four morphine sulfate patches). Therefore, the first action should be to address this problem by removing the patches.

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Correct Answer is B

Explanation

Choice A rationale

While a thyroid function test could be relevant in some cases, it is not the most pertinent in this situation. The symptoms described by the patient do not suggest a thyroid issue.

Choice B rationale

The symptoms described by the patient, such as fatigue, nausea, dark urine, and yellowing of the skin and sclera, are indicative of liver dysfunction. Albendazole is primarily metabolized in the liver, and its use can cause liver damage in some cases. Therefore, a liver function test would be the most appropriate laboratory result to review.

Choice C rationale

While a renal function panel could be relevant in some cases, it is not the most pertinent in this situation. The symptoms described by the patient do not suggest a kidney issue.

Choice D rationale

A basic metabolic panel could provide useful information about various aspects of the patient’s health, but it is not the most relevant test given the patient’s symptoms and medication.

A. St. John’s Wort can decrease plasma concentrations of cyclosporine. B. Consumption of St. John’s Wort can reduce the patient’s sodium intake. C. Adding the herb can decrease the need for corticosteroids. D. The patient probably used this herb to treat depression.

Correct Answer is A

Explanation

Choice A rationale

St. John’s Wort is known to interact with many prescription drugs, including cyclosporine, a medication often given to transplant patients to prevent organ rejection. St. John’s Wort can decrease plasma concentrations of cyclosporine, thus endangering the success of organ transplantations.

Choice B rationale

There is no evidence to suggest that consumption of St. John’s Wort can reduce the patient’s sodium intake.

Choice C rationale

Adding the herb does not decrease the need for corticosteroids. In fact, it can interact with many medications and cause serious complications.

Choice D rationale

While St. John’s Wort is often used to treat depression, in the context of a patient who has undergone a renal transplant, the most significant information is its potential to interact with cyclosporine and endanger the success of the transplant.

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Naxlex Comprehensive Predictor Exams

A patient who is taking albendazole reports experiencing fatigue, nausea, and dark urine. The nurse observes a yellowing of the patient’s skin and sclera.Which laboratory result should the nurse review?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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